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10. Equity, ethical and other considerations

10.1 Equity

If the costs of the vaccine and its administration are to be paid by individuals themselves and not publicly funded, access to HPV vaccination will be problematic. In the past, when vaccines were not publicly funded, there was inequity of access. In Canada, social disparities exist in the utilization of cervical cancer screening(80), and cervical cancer affects mainly women of lower socio-economic status(81). The absence of a publicly funded HPV immunization program would introduce an inequity in HPV and cancer prevention. A school-based immunization program could reduce these disparities by inclusion of all girls who go to school, without regard to their socio-economic characteristics. However, if no catch-up is implemented, such a program would remain inequitable for the teenagers outside the targeted school groups and for the women from 15 to 26 years old who are not going to school but for whom HPV vaccine is recommended.

Although the vaccine is not currently recommended for men, they could be equally concerned about HPV and the possible effects of the virus on their health. If future clinical studies demonstrate the efficiency of HPV vaccines for men and the vaccine is authorized for sale in men, ethical and equity issues will have to be re-examined.

10.2 Ethical considerations

Because it is a sexually transmitted disease, HPV infection is different from many other vaccine preventable diseases, such as mumps, measles, rubella or varicella. This difference could create ethical dilemmas, many of them originating in the concern about sending a morally wrong message, such as endorsement of sexual promiscuity. Vaccination against hepatitis B, a virus that can also be transmitted through sexual contact, is now part of the publicly funded immunization programs offered in all provinces and territories(82). Even if similar concerns were raised, implementation of hepatitis B immunization programs has not prompted major parental opposition in Canada. In a review of relevant studies, only between 6% and 12% of parents were concerned about the impact of HPV vaccination on the sexual activity of their child(54, 62, 65, 83). Furthermore, safe sex and abstinence messages are not inconsistent with HPV vaccination. Finally, HPV vaccination will be voluntary in Canada; its use should not be compulsory and not lead to school-based requirements.

10.3 Other considerations

HPV vaccines are licensed in more than 60 countries(84). Routine immunization programs have been implemented in a number of industrialized countries, including the United States, Australia and western European countries.

Canadian recommendations to implement a routine HPV program for girls ranging from 9 to 14 years of age, with catch-up programs where feasible, are in line with program recommendations from other countries. In general, routine programs primarily target females prior to adolescence and age of onset of sexual activity. Several countries in which HPV programs have been implemented have chosen a narrower age range than Canada for their routine immunization programs, including girls aged 11 and 12 years in the United States, girls aged 14 in France, girls aged 12 and 13 in Australia and girls aged 12 in Italy (Table 3). Catch-up programs have also been recommended in all of these countries to capture older females up to 26 years of age. Austria differs from most countries in that HPV is recommended for both boys and girls 9 to 15 years of age.